Healthcare Provider Details

I. General information

NPI: 1285455527
Provider Name (Legal Business Name): LONGEVITY MEDICAL INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 VILLAS DEL MAR
SAN JOSE DEL CABO BAJA CALIFORNIA SUR
23406
MX

IV. Provider business mailing address

4521 SAN FELIPE ST UNIT 2902
HOUSTON TX
77027-3388
US

V. Phone/Fax

Practice location:
  • Phone: 702-401-9300
  • Fax:
Mailing address:
  • Phone: 702-401-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KIRK SANFORD
Title or Position: CEO
Credential: DC
Phone: 702-401-8930